Pre-Employment Screening

Employment Pre-Screening Application

"*" indicates required fields

Position Applying For*

Name*

First Last

Phone*

Alternate Phone

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Type of employment desired*

Full time

Part time

Date you can start work if hired*

Days of the week you are available to work*

Sun

Mon

Tues

Wed

Thurs

Fri

Sat

Are you available for the following*

On-Call

Holidays

Shifts you are available to work*

Day shift

Night shift

Work Experience

Please list the names of your present and/or previous employers in chronological order with present or last employer listed first. Account for ALL periods of time including any period of unemployment. If self-employed, supply firm name and business references. You may include any verifiable work performed on a volunteer basis, internships, or military service. Your failure to completely respond to each inquiry may disqualify you for consideration from employment.

Employer 1

Business or Organization Name

Type of Business

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Start Date

End Date

Job Title

Duties

Supervisor's Name

First Last

May we contact?

Yes

No

If "no," why not?

Starting Wages

Ending Wages

Reason for Leaving

How much notice did you give when resigning? If none, explain.

What will this employer say was the reason your employment terminated?

Employer 2

Business or Organization Name

Type of Business

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Start Date

End Date

Job Title

Duties

Supervisor's Name

First Last

May we contact?

Yes

No

If "no," why not?

Starting Wages

Ending Wages

Reason for Leaving

How much notice did you give when resigning? If none, explain.

What will this employer say was the reason your employment terminated?

Offices

1-855-309-8243
Office: 205-942-7211
Fax: 877-224-0679

Birmingham

500 Robert Jemison Road
Birmingham, AL 35209
Email: info@advancingsight.org
Phone: 1.800.423.7811
Fax: 1.205.942.2129

Mobile

3929 Airport Blvd
Bldg. 2 Suite 403
Mobile, AL 36609
Email: mobile@advancingsight.org
Phone: 1.205.313.8345
Fax: 1.205.942.2129

Memphis

3144 Stage Post Drive
Suite 116
Bartlett, TN 38133
Email: midsouth@advancingsight.org
Phone: 1.901.446.0927
Fax: 1.888.700.4801

Huntsville

701 Genome Way Northwest
Suite F – Lab 130
Huntsville, AL 35806
Email: huntsville@advancingsight.org
Phone: 1.205.313.8341
Fax: 1.256.534.3713

Montgomery

400 Eastern Blvd, Suite 100
Montgomery, AL 36117
Email: montgomery@advancingsight.org
Phone: 1.205.313.8343
Fax: 877-233-0679

Pre-Employment Screening

Employment Pre-Screening Application

Work Experience

Employer 1

Employer 2

Sign up for Advancing Sight News.